| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 017025 | (X3) Date Survey Completed 04/03/2025 |
| Name of Provider or Supplier Saad Enterprises, Inc. | Street Address, City, State 1515 University Blvd, South, Mobile, AL | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| G0580 | Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on medical record (MR) review, agency policy, and interview with staff, it was determined the agency failed to ensure physician's orders were followed. This deficient practice affected one of four diabetic patients reviewed including MR # 7 and had the potential to affect all diabetic patients admitted to this agency. Findings include: Agency Policy: Physician Notification and Physician Orders Policy Number: Not Listed Revised: 2/2025 Section 1: Purpose/Objective 1.1 To ensure that the physician is notified of all changes in patient status... 1.2 To ensure that all disciplines follow all orders, to include the 485/487 and Physician Change Orders... 1. MR # 7 was admitted on 8/16/24 with diagnoses including Dysphagia Following Cerebral Infarction, Peripheral Vascular Disease, and Type 2 Diabetes Mellitus. Review of the Resumption of Care (ROC) dated 8/28/24 revealed physician's orders for Skilled Nurse (SN) one visit per week for seven weeks. SN to perform blood glucose analysis every visit and report blood glucose levels greater than 250 milligrams (mg)/deciliter(dl) and less than 70 mg/dl. Review of the SN Visit Note Report dated 9/10/24 revealed no documentation the SN obtained the blood glucose level. Review of the SN Visit Note Report dated 9/12/24 revealed the SN documented the blood glucose was 45 mg/dl and MR # 7 was taken to the Emergency Room. An interview was conducted on 4/3/25 at 11:04 AM with Employee Identifier (EI) # 1, Director of Nursing, who confirmed the agency failed to ensure the staff followed physician orders for performing blood glucose analysis every visit. |